32 Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021 33Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021

Case Report

INTRODUCTION

Cleft lip and/or palate is the most common congenital

defect of the oral cavity.1 In context of Nepal, the incidence

of cleft lip and/or palate in Eastern Nepal was found to be

1.64/1000 live births per year.2 Among the various types of

cleft, cleft lip and palate (CLP) is the most common type.

Bilateral CLP is a congenital malformation in which the

premaxilla is suspended from the tip of the nasal septum

along with a significantly increased alar base width.3

Bilateral CLP with a severely protruded premaxillary

segment can present as a challenge during the surgical lip

repairing. Pre-surgical alveolar molding, as described in

this case report is one of the infant orthopedics technique

which aids in the approximation of the cleft segments

thereby improving the esthetic result of the surgical repair.

CASE REPORT

A 5-day-old neonate, who was born by Caesarian delivery,

presented to the department of Pedodontics and Preventive

Pre-surgical Alveolar Molding: An Adjunct to Surgical Repair in Cleft Lip and Palate Rehabilitation

Rikta Pande,1 Bandana Koirala,2 Mamta Dali,3 Kabiraj Poudel4

1Junior Resident, 2Professor, 3Associate Professor, 4Consultant Pedodontist

1-3Department of Pedodontics and Preventive Dentistry, College of Dental Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, 4Mugu District Hospital, Mugu, Nepal.

J Nepal Assoc Pediatr Dent. 2021;2(1):32-5

ABSTRACT

Bilateral cleft lip and palate (CLP) with a severely protruded premaxillary segment can present as a challenge during surgical lip

repairing. Pre-surgical alveolar molding, as described in this case report, is one such technique which aids in the approximation of

the cleft segments thereby improving the esthetic result of the surgical repair. The present case highlights the importance of a simple

molding appliance in re-positioning the protruded premaxillary segments of a neonate with bilateral CLP thereby serving as an

adjunct to the surgical repair.

Keywords: Bilateral cleft lip and palate, lip taping, premaxillary segment, pre-surgical alveolar molding.

Dentistry, B.P. Koirala Institute of Health Sciences, with the

chief complaint of inability in suckling milk and passage of

fluids through the nose (Figure 1, 2). There was no positive

family history. Pre-natal history revealed no any illnesses,

history of alcohol consumption, medication intake, trauma

or hospitalization during pregnancy.

On clinical examination, bilateral complete clefts of the

lip, hard and soft palate was found, with nasal deformity

and a dis placed alveolar segment. Clinically, it was

characterized under Veau’s Class IV classification (Figure

3).4 No other associated syndromes could be appreciated.

Alveolar molding technique was planned. Both the risks

and benefits were explained to the parents, but the parents

seemed unwilling because of the tedious, initial follow-up

schedule. However, after one month, they revisited and

agreed upon undergoing the therapy. Informed parental

consent was then obtained.

An impression of the cleft was taken when the infant was

fully awake by using a heavy body polyvinyl siloxane

impression material (Dentsply Sirona) in an acrylic custom

tray (Figure 4). Impression was taken in the Pedodontics

department itself with a medical officer present as a part of

the impression team. While making impression, the baby

was kept in his father’s lap with head facing downward

(inverted position) to allow the fluids to drain out of the

oral cavity while the father’s hands supported the baby’s

Correspondence

Dr. Rikta PandeJunior Resident, Department of Pedodontics and Preventive Dentistry, BPKIHS, Dharan, Nepal.E-mail: riktapande@gmail.com

Citation

Pande R, Koirala B, Dali M, K Poudel. Pre-surgical Alveolar

Molding: An Adjunct to Surgical Repair in Cleft Lip and Palate

Rehabilitation. J Nepal Assoc Pediatr Dent. 2021;2(1):32-5.

32 Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021 33Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021

chest and lap region during the entire procedure. Once

the impression material was set, the tray was removed, and

oral cavity was inspected for the presence of any residual

impression material in the cleft region.

Cast was then poured, trimmed and an alveolar molding

appliance was fabricated by using self-cure acrylic resin of

2–3 mm thickness (Figure 5, 6). The appliance was finished

and polished to ensure that all tissue borders were smooth

and polished. A retention arm of acrylic was made at an

angle of 40 degrees from the plate. A notch was created on

the retention arm to grasp the elastics. The appliance was

then inserted into the patient’s mouth and was checked for

proper fit and retention (Figure 7). The primary retention

of the appliance was obtained by using extra-oral facial

tapes (Micropore tape and Tegaderm) and elastics of an

internal diameter 0.25 inches.

Parents were given proper instructions regarding feeding

and maintenance of the appliance. They were asked and

taught to feed the child with the appliance in place. The

infant must be able to suckle and swallow without gagging

or struggling. They were also asked to clean the appliance

daily with drinking water. Parents were demonstrated

Figure 1. Extra-oral Photograph (Frontal View).

Figure 4. Primary Impression.

Figure 7. Appliance In Situ.

Figure 2. Extra-oral Photograph (Lateral View).

Figure 5. Preliminary Cast .

Figure 8. Post-treatment photograph taken at three months follow-up

(Frontal View).

Figure 3. Veau’s Class IV Cleft lip and palate.

Figure 6. AlveolarMolding Plate.

Figure 9. Post-treatment photograph taken at three months follow-up

(Lateral View).

Pande et al. Pre-surgical Alveolar Molding: An Adjunct to Surgical Repair in Cleft Lip and Palate Rehabilitation

34 Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021 35Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021

Pande et al. Pre-surgical Alveolar Molding: An Adjunct to Surgical Repair in Cleft Lip and Palate Rehabilitation

and trained on the removal and placement of elastics and

changing of tapes every day and to keep the appliance in

place at all times except during cleaning.

Patient was recalled after 24 hours to evaluate and

correct problems associated with the appliance (if any).

Thereafter, the recall appointments were scheduled

weekly for making further adjustments. During these visits,

serial modification of the appliance was done by selective

trimming and addition of the soft liner, depending on the

direction in which the bone movement was required. The

modification was done by making 0.5 – 1 mm increments

during each visit.

Follow-up evaluation at three months post appliance

placement showed an appreciable close approximation of

cleft alveolar gap (Figure 8, 9). A nasal stent was planned

for the correction of nasal deformity when the cleft gap

would reach approximately 5-6 mm but it could not be

given to this patient since the infant was already four

months of age. At this time, oral and maxillofacial surgeon

had planned for the surgery of cleft lip thus the patient was

finally sent to maxillofacial and plastic surgery team for

further treatment.

DISCUSSION

Bilateral CLP is a congenital malformation where the pre-

maxilla is often rotated to one side. The greatest challenge

for reconstruction is the protruded pre-maxilla.3 If the

lip segments are sutured while the pre-maxilla is still

protruded, the surgical closure of the lip can be extremely

difficult and due to the uncontrolled tension applied by

the scarred lip, over-extrusion and bending of the pre-

maxilla are inevitable. Here pre-surgical alveolar molding

can bring about a promising result in solving many such

problems of bilateral CLP to a great extent. Alveolar

molding prior to primary cheiloplasty will not only provide

psychological reassurance to the parents and child but

also enhance the surgical outcome and reduce the need

for revision surgeries in the future, thereby reducing the

overall cost of the treatment.5

Pre-surgical naso-alveolar molding appliance works on the

principle of ‘negative sculpturing’ and ‘passive molding’

of the alveolus and the adjacent soft tissues.6 In passive

molding, a custom-made molding plate of the acrylic is

used to gently direct growth of the alveolus to get the

desired results later on. While in negative sculpturing,

serial modifications are made in certain areas of the

internal surfaces of the molding appliance, with addition

or deletion of material to get the desired shape of alveolus

and the nose.6

The present case reports a case of a newborn patient

who had a complete bilateral cleft lip and palate and was

aided by an alveolar molding plate that facilitated both the

feeding as well as approximation of the cleft segments. Pre-

surgical alveolar molding appliance provided alignment of

the displaced segments, which enabled the surgeons and

the patient to enjoy the benefits associated with the repair

of cleft deformities with minimum number of surgeries

and their complications.

The clinical procedures and fabrication of the alveolar

molding plate should be started in the first week or the

early second week after birth,1 as per the Matsuo and

Hirose’s hypothesis of Pre-surgical naso-alveolar molding

which conceptualizes that the nasal cartilage is still

developing and is subject to repositioning within the first 6

weeks of life.7 Molding of the tissues can be easily achieved

during early life, because of raised levels of hyaluronic

acid and maternal circulating estrogen levels present in

the neonates.7 However, cases have been reported in

which alveolar molding has been attempted even in three

months old baby.8 In the present case, alveolar molding

was started when the infant was 36 days old. Despite the

fact that the infant reported one month late for treatment,

a good treatment result could be achieved as the molding

plate therapy yielded a significant reduction of cleft width

in this case.

As accordance to the authors, Grayson and Shetye9 when

the alveolar gap is approximated (up to five mm) and the

arch is aligned, a nasal molding device is added to the

orthopedic appliance to increase the columella length as

well as to reshape the alar dome. Following this principle,

in the present case the nasal stent was not incorporated

till the alveolar gap was reduced to almost five mm.

Nonetheless, there are other techniques too where alveolar

and nasal molding is performed simultaneously using an

acrylic plate with rigid acrylic nasal extension.10 Further

studies comparing both the techniques would be helpful

to better understand the results.

34 Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021 35Journal of Nepalese Association of Pediatric Dentistry : Vol. 2, No. 1, Jan-Dec, 2021

REFERENCES1. Laxmikanth SM, Karagi T, Shetty A, Shetty S. Nasoalveolar molding: A review. JCRI. 2014;1(3):108-13. [Full Text | DOI]

2. Singh VP, Sagtani R, Sagtani A. Prevalence of cleft lip and cleft palate in a tertiary hospital in Eastern Nepal. Mymensingh Med J. 2012 Jan;21(1):151-4. [PubMed]

3. Broadbent TR, Woolf RM. Cleft lip nasal deformity. Ann Plast Surg. 1984 Mar;12(3):216-34. [PubMed | DOI]

4. Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate Craniofac J. 2017 Mar;54(2):175-188. [PubMed | DOI]

5. Mathew A, Muddaiah S, Subrahmanya JB, Somaiah S, Shetty B, Reddy G. Presurgical nasoalveolar molding in a 4-day-old infant with unilateral cleft lip, alveolus, and palate deformity. APOS Trends Orthod 2018;8:225-9. [Full Text | DOI]

6. Dubey RK, Gupta DK, Chandraker NK. Presurgical nasoalveolar molding: A technical note with case report. Indian J Dent Res Rev 2011;2:66-8. [Full Text]

7. Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S, Takahashi N, Koh B. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 1984 Jan;73(1):38-51. [PubMed | Full Text | DOI]

8. Attiguppe PR, Karuna YM, Yavagal C, Naik SV, Deepak BM, Maganti R, Krishna CG. Presurgical nasoalveolar molding: A boon to facilitate the surgical repair in infants with cleft lip and palate. Contemp Clin Dent. 2016 Oct-Dec;7(4):569-573. [PubMed | Full Text | DOI]

9. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg. 2004 Apr;31(2):149-58. [PubMed | Full Text | DOI]

10. Singh A, Thakur S, Singhal P, Diwana VK, Rani A. A Comparative Evaluation of Efficacy and Efficiency of Grayson’s Presurgical Nasoalveolar Molding Tech-nique in Patients with Complete Unilateral Cleft Lip and Palate with Those Treated with Figueroa’s Modified Technique. Contemp Clin Dent. 2018 Jun;9(Suppl 1):S28-S33. [PubMed | Full Text |DOI]

Pande et al. Pre-surgical Alveolar Molding: An Adjunct to Surgical Repair in Cleft Lip and Palate Rehabilitation

JNAPD

CONCLUSIONS

With an aid of simple molding appliance therapy such

as pre-surgical alveolar molding, a clinically visible

approximation of the cleft alveolar segments was achieved

along with an appreciable repositioning of the protruded

pre-maxillary segment. Thus, Pre-surgical alveolar

molding served as a valuable adjunct in the present case

that enabled the surgeons to repair the cleft lip and palate

without extensive tissue tension and the need for multiple

surgeries along with great patient satisfaction.

Conflict of Interest: None